Pseudoachalasia as the first manifestation of signet-ring cell duodenal carcinoma.

INTRODUCTION: Pseudoachalasia is a rare clinical condition, often caused by malignancy. Rarely, this entity can reveal the underlying neoplasia. To the best of our knowledge, we report the first case of pseudoachalasia revealing a metastatic signet-ring cell carcinoma of the non-ampullary duodenum. CASE REPORT: A previously healthy 67-year-old patient presented with a 3-month history of rapidly progressive intermittent dysphagia with 20kg weight loss. An upper endoscopy showed multiple duodenal ulcerations on congestive mucosa. Duodenal biopsies revealed tumor proliferation formed by independent cells with atypical nuclei. In immunohistochemistry, tumor cells expressed pan-cytokeratin. Esophageal manometry revealed an aspect in favor of achalasia type II. The CT scan showed ascites and pleural effusion. Their punctures confirmed the presence of neoplastic cells. The diagnosis of metastatic signet-ring cell duodenal carcinoma revealed by pseudoachalasia was retained. CONCLUSION: In the presence of rapidly progressive symptoms with significant weight loss, especially in the elderly patients, malignancyassociated pseudoachalasia should be suspected.

Prevalence and risk factors for vitamin D deficiency in Crohn disease patients: A Tunisian study.

INTRODUCTION: Vitamin D plays a role in regulating the immune response through an immunomodulatory effect, and is probably involved in the pathophysiology of Crohn's disease (CD). AIM: to assess vitamin D status in patients with CD as well as in healthy controls and to determine associated factors of vitamin D deficiency in patients with CD. METHODS: We conducted a prospective study over 18 months, including CD patients with age and sex matched with healthy controls. Suboptimal vitamin D status was defined by vitamin D serum level < 30 ng/ml, vitamin insufficiency by vitamin D serum level between 10 and 30 ng/ml and vitamin deficiency serum level < 10 ng/ml. RESULTS: We included 77 subjects (52 patients with CD and 25 controls) with mean age of 38 years± 11. Most patients and controls had suboptimal levels of vitamin D (98% and 96% respectively) including vitamin D deficiency in 75% and 67%, respectively and vitamin D insufficiency in 25% and 33%, respectively. In univariate analysis, vitamin D deficiency was associated with disease flare-up (p=0.001), anemia (p=0.002), hypo-albuminemia (p=0.002), elevated C-reactive protein (CRP) (p=0.003), Crohn's Disease Activity Index (CDAI) (p<0.001), ileal location (p=0.04) and immunosuppressive therapy (p=0.01). In multivariate analysis, only CDAI was significantly associated with vitamin D deficiency (p=0.003, OR=9.33). CONCLUSION: Vitamin D deficiency is common in Tunisian CD patients as well as in controls and is associated with disease activity.

Primary hepatic large B-cell lymphoma following direct-acting antiviral treatment for hepatitis C.

Hepatitis C virus (HCV) infection is a major public health concern worldwide, raising important medical and economic issues. HCV-related end-stage liver disease is one of the most common indications for hepatic transplantation. Chronic hepatitis C is also assimilated to a systemic disease because of multiple extrahepatic manifestations, including lymphoproliferative disorders. The revolution of HCV treatment with the advent of direct-acting antivirals has significantly improved the management with high antiviral efficacy and good safety profile compared with old regimens, thus allowing good outcomes on hepatic and extrahepatic symptoms. However, with the widespread use of these new agents, controversial concerns about unexpected increasing cases of hepatocellular carcinoma were reported. We now report the case of a patient presenting with HCV-related cirrhosis, treated with direct-antiviral therapy and diagnosed with primary hepatic lymphoma shortly after the end of the treatment.